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/ V <br /> �j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQE: OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, _ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 -a3/td <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin ' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0&/" -YU CENSUS TRACT ' <br /> Owner's Name Phone - ' <br /> Address <br /> iCity d dV <br /> - Ir <br /> 2 z cA 1p <br /> Contractor's Name License # ✓ Phone f //7 <br /> TYPE OF WORK (Check) ; NEW WELL /X/DEEPEN /�/ RECONDITION_/_/ DESTRUCTION <br /> AL !W7 <br /> PUMP INSTALLATION / -/ PUMP REPAIR/—/—PUMP PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TA14K 09Q 34 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven r Gauge of Casing � <br /> Irrigation Gravel Pack Depth of Grout Seal S`y <br /> Other Rotary Type of Grout _ _-- <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' � <br /> PUMP REPLACEMENT: f / State Work Done <br /> PUMP PAIR: / / State Work Done <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> E SIGNED e+rs., TITLE <br /> G <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY / <br /> i PHASE I DATE <br /> r4 APPLICATION ACCEPTED .BY <br /> ADDITIONAL COXENTS: <br /> PHASE II GROUT INSPECTION PHASE JI FIML INSPECTION <br /> INSPECTIOIa BY DATE / <br /> INSPECTION BYd�/ DATE <br /> CALL FOR A ' OUT NS E ON PRIC7R TO G OUTING X FINAL INSPECTION. �u'�"'7•' `j� > �` <br />